GW1--00659_Well Construction - GW1_20240119

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WELL CONSTRUCTION RECORD (GW-1) For Internal Use Only: 1 1 - __I.Well Contractor Information:
I
RANDY OWNBEY 14.WATER ZONES I l
Well Contractor Name FROM TO DESCRIPTION
3214A 189 ft. 205 ft.
ft. ft.
NC Well Contractor Certification Number
AIR DRILLING INC 15.OUTER CASING(for multi-cased ivells)OR LINER(if applicable)
FROM TO DIAMETER 1 THICKNESS MATERIAL
Company Name 0 ft. 107 ft. 6 I li). GALV
2023-27255 16.INNER CASING OR TUBING(geothermal closed-loop)
2.Well Construction Permit#: FROM TO DIAMETER ; THICKNESS MATERI\I.
List all applicable well consirnt•lion permits(i.e.U/C,Coaaty,Stale, Variance,etc.) ft. ft. , in.
3.Well Use(check well use): ft. ft. '' in.
Water Supply Well: I7,SCREEN
Agricultural FROM TOft. ft.
DIAMETER Slot'SIZE THICKNESS MATERIALMATERIAL[�Mwticipal/Public in.
I
Geothermal(Heating/Cooling Supply) Residential Water Supply(single)
ft. in.
Industrial/Commercial DResidential Water Supply(shared)
18.GROUT ft.
Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 rl. 20 It' GROUT POURED
Monitoring Recovery ft. ft.
In Well:
ft. ft.
19.SAND/GRAVEL PACK(Ifapplicnble)
FROM TO
ft.
Aquifer Recharge f Groundwater Renlediation
Aquifer Storage and Recovery Salinity Barrier MATERIAL EMPLACEMENT METHOD
Aquifer Test DStormwater Drainage ft.
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) D1'racer 20.DRILLING LOGSattnch ndditional'sheots If necessary)
Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) Iutoa7 ro DESCRIPTION(color,hnrrthess,soil/ruck type,grain size,etc.)
0 f`' 97 f`' DIRT
4.Date Well(s)Completed: 0$"29-2023 Well ID/l 97
rt. 205 ft. ROCK
5a.Well Location: ft. ft.
REGINA SLAUGHTER ft. ft. - --.Z.T. -
Facilil Facility/Owner Nameft. ft. _� IL,L s {r,
Y Facility 1DR(ifapplicablc) �" " ' �y L
541 BROOKHAVEN RD,STATESVILLE,N.C. 28677 ft. ft. JAiV
—e et
Physical Address,City,and Zip ft. rt.
lnr-"' `' :,,
4811-46-8174 21.REMARKS ' )•^
IREDELL ?. g UI
idvwCyzoci,
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(it'well field,one lat/long is sufficient) 22.Certifi , ' n:
35° 58.653 N 80° 58.631 W
' 08-29-2023
6.Is(are)the well(s)0Permanent or D'1'omporary Signature of Certified Well Contractor Dale
By signing this form,/hereby effigy that the»ell(s)was(were)constructed in accordance
7.Is this a repair to an existing well: DYes or DNo with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 itell C:onstruclimr Standards and that a
If this is a repair,fill out known well construction information and explain the nature of/he copy rffhis record has been provided sided to the well owner.
repair under 02/remarks section or on the back of this form. !
23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to'provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details, You may also attach additional pages if necessary.
drilled:
SUBMITTAL INSTRUCTIONS '
9.Total well depth below land surface: 205 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mahiple weds 11.sr all depths iifdttlerenl(example-3@200'and 2 rt 100') construction to the following:
10.Static water level below top of casing: 45 (ft.) Division of Water Resource's,Information Processing Unit,
If wale,'level is above casing,use"+" 1617 Mail Service Conlin.,Raleigh,NC 27699-1617
11.Borehole diameter: 6 (in.) 24b. For Infection Wells: in addition to sending the form to the address in 24a
above, also submit one copy of this form within 30 (lays of completion of well
12.Well construction method:
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centcr,'Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: AIR 24c. For Water Supply &Injection Wells: In addition to sending the form to .
•
HTH the address(es) above, also submit one'copy of this form within 30 clays of
13b.Disinfection type: Amount: • completion of well construction to the county health department of the county
where constructed.
Form OW-I North Carolina Department of Environmental Quality-Division of Water Resources I Revised 2-22-2016